WITHDRAWN: Evaluation of Fourier Transform Infrared spectroscopy (IR Biotyper) as a complement to Whole genome sequencing (WGS) to characterise Enterobacter cloacae , Citrobacter freundii and Klebsiella pneumoniae isolates recovered from hospital sinks

The authors have withdrawn their manuscript due to becoming aware of methodology issues related to the curation of the training set used to determine cut-off values for Biotyper cluster assignation and lack of replicate measurements on different days for the isolates analysed. It is therefore unclear whether the conclusions of the manuscript are founded and no further work is possible to correct these issues as the instrument is no longer available to the authors. If you have any questions, please contact the corresponding author.

A workflow for the detection of antibiotic residues, measurement of water chemistry and preservation of hospital sink drain samples for metagenomic sequencing

BACKGROUND

Hospital sinks are environmental reservoirs that harbour healthcare-associated (HCA) pathogens. Selective pressures in sink environments, such as antibiotic residues, nutrient waste and hardness ions, may promote antibiotic resistance gene (ARG) exchange between bacteria. However, cheap and accurate sampling methods to characterize these factors are lacking.

AIMS

To validate a workflow to detect antibiotic residues and evaluate water chemistry using dipsticks. Secondarily, to validate boric acid to preserve the taxonomic and ARG ('resistome') composition of sink trap samples for metagenomic sequencing.

METHODS

Antibiotic residue dipsticks were validated against serial dilutions of ampicillin, doxycycline, sulfamethoxazole and ciprofloxacin, and water chemistry dipsticks against serial dilutions of chemical calibration standards. Sink trap aspirates were used for a 'real-world' pilot evaluation of dipsticks. To assess boric acid as a preservative of microbial diversity, the impact of incubation with and without boric acid at ∼22 °C on metagenomic sequencing outputs was evaluated at Day 2 and Day 5 compared with baseline (Day 0).

FINDINGS

The limits of detection for each antibiotic were: 3 μg/L (ampicillin), 10 μg/L (doxycycline), 20 μg/L (sulfamethoxazole) and 8 μg/L (ciprofloxacin). The best performing water chemistry dipstick correctly characterized 34/40 (85%) standards in a concentration-dependent manner. One trap sample tested positive for the presence of tetracyclines and sulphonamides. Taxonomic and resistome composition were largely maintained after storage with boric acid at ∼22 °C for up to five days.

CONCLUSIONS

Dipsticks can be used to detect antibiotic residues and characterize water chemistry in sink trap samples. Boric acid was an effective preservative of trap sample composition, representing a low-cost alternative to cold-chain transport.

Pre-hospital ECPR in an Australian metropolitan setting: a single-arm feasibility assessment-The CPR, pre-hospital ECPR and early reperfusion (CHEER3) study

INTRODUCTION

Survival from refractory out of hospital cardiac arrest (OHCA) without timely return of spontaneous circulation (ROSC) utilising conventional advanced cardiac life support (ACLS) therapies is dismal. CHEER3 was a safety and feasibility study of pre-hospital deployed extracorporeal membrane oxygenation (ECMO) during cardiopulmonary resuscitation (ECPR) for refractory OHCA in metropolitan Australia.

METHODS

This was a single jurisdiction, single-arm feasibility study. Physicians, with pre-existing ECMO expertise, responded to witnessed OHCA, age < 65 yrs, within 30 min driving-time, using an ECMO equipped rapid response vehicle. If pre-hospital ECPR was undertaken, patients were transported to hospital for investigations and therapies including emergent coronary catheterisation, and standard intensive care (ICU) therapy until either cardiac and neurological recovery or palliation occurred. Analyses were descriptive.

RESULTS

From February 2020 to May 2023, over 117 days, the team responded to 709 "potential cardiac arrest" emergency calls. 358 were confirmed OHCA. Time from emergency call to scene arrival was 27 min (15-37 min). 10 patients fulfilled the pre-defined inclusion criteria and all were successfully cannulated on scene. Time from emergency call to ECMO initiation was 50 min (35-62 min). Time from decision to ECMO support was 16 min (11-26 min). CPR duration was 46 min (32-62 min). All 10 patients were transferred to hospital for investigations and therapy. 4 patients (40%) survived to hospital discharge neurologically intact (CPC 1/2).

CONCLUSION

Pre-hospital ECPR was feasible, using an experienced ECMO team from a single-centre. Overall survival was promising in this highly selected group. Further prospective studies are now warranted.

Appropriateness of acute-care antibiotic prescriptions for community-acquired infections and surgical antibiotic prophylaxis in England: analysis of 2016 national point prevalence survey data

BACKGROUND

Estimates of inappropriate prescribing can highlight key target areas for antimicrobial stewardship (AMS) and inform national targets.

OBJECTIVES

To (1) define and (2) produce estimates of inappropriate antibiotic prescribing levels within acute hospital trusts in England.

METHODS

The 2016 national Healthcare-Associated Infections (HAI), Antimicrobial Use (AMU) and AMS point prevalence survey (PPS) was used to derive estimates of inappropriate prescribing, focusing on the four most reported community-acquired antibiotic indications (CAIs) in the PPS and surgical prophylaxis. Definitions of appropriate antibiotic therapy for each indication were developed through the compilation of national treatment guidelines. A Likert-scale system of appropriateness coding was validated and refined through a two-stage expert review process.

RESULTS

Antimicrobial usage prevalence data were collected for 25,741 individual antibiotic prescriptions, representing 17,884 patients and 213 hospitals in England. 30.4% of prescriptions for the four CAIs of interest were estimated to be inappropriate (2054 prescriptions). The highest percentage of inappropriate prescribing occurred in uncomplicated cystitis prescriptions (62.5%), followed by bronchitis (48%). For surgical prophylaxis, 30.8% of prescriptions were inappropriate in terms of dose number, and 21.3% in terms of excess prophylaxis duration.

CONCLUSIONS

The 2016 prevalence of inappropriate antibiotic prescribing in hospitals in England was approximated to be 30.4%; this establishes a baseline prevalence and provided indication of where AMS interventions should be prioritized. Our definitions appraised antibiotic choice, treatment duration and dose number (surgical prophylaxis only); however, they did not consider other aspects of appropriateness, such as combination therapy - this is an important area for future work.

Intermittent point prevalence surveys on healthcare-associated infections, 2011 and 2016, in England: what are the surveillance and intervention priorities?

BACKGROUND

Point prevalence surveys are an important surveillance method for determining the burden of healthcare-associated infections (HCAIs).

AIM

To outline the key results of two point prevalence surveys in England (2011 and 2016).

METHODS

All National Health Service and independent sector hospitals in England were eligible to participate. Data were collected between September and November in both 2011 and 2016 based on the protocol and codebook devised by the European Centre for Disease Prevention and Control. Analysis was performed using Stata Version 13 and SAS Version 9.3. A mixed-effects model was applied, which allowed estimation of organization-specific means and accounted for the heterogeneity in the responses from different organizations.

FINDINGS

A total of 100,755 case records were included (52,433 in 2011 and 48,312 in 2016). The estimated prevalence of HCAIs was slightly higher in 2016 [6.89%, 95% confidence interval (CI) 6.21-7.57%] than in 2011 (6.41%, 95% CI 5.75-7.06%). In both surveys, the prevalence of HCAIs was highest in adult intensive care units (23.1% in 2011, 21.2% in 2016), and pneumonia/lower respiratory tract infections was the most common cause of HCAIs (22.7% in 2011 vs 29.2% in 2016). Inpatients in acute hospitals were older and had higher risk of dying in 2016 compared with 2011; however, the proportion of inpatients with HCAIs or on antibiotics did not differ significantly.

CONCLUSION

The burden of HCAIs in English hospitals increased slightly between 2011 and 2016. However, the proportion of inpatients with HCAIs or on antibiotics did not differ significantly.

Phase I study of liver depot gene therapy in late-onset Pompe disease

Gene therapy with an adeno-associated virus serotype 8 (AAV8) vector (AAV8-LSPhGAA) could eliminate the need for enzyme replacement therapy (ERT) by creating a liver depot for acid α-glucosidase (GAA) production. We report initial safety and bioactivity of the first dose (1.6 × 1012 vector genomes/kg) cohort (n = 3) in a 52-week open-label, single-dose, dose-escalation study (NCT03533673) in patients with late-onset Pompe disease (LOPD). Subjects discontinued biweekly ERT after week 26 based on the detection of elevated serum GAA activity and the absence of clinically significant declines per protocol. Prednisone (60 mg/day) was administered as immunoprophylaxis through week 4, followed by an 11-week taper. All subjects demonstrated sustained serum GAA activities from 101% to 235% of baseline trough activity 2 weeks following the preceding ERT dose. There were no treatment-related serious adverse events. No subject had anti-capsid T cell responses that decreased transgene expression. Muscle biopsy at week 24 revealed unchanged muscle glycogen content in two of three subjects. At week 52, muscle GAA activity for the cohort was significantly increased (p < 0.05). Overall, these initial data support the safety and bioactivity of AAV8-LSPhGAA, the safety of withdrawing ERT, successful immunoprophylaxis, and justify continued clinical development of AAV8-LSPhGAA therapy in Pompe disease.

Development and implementation of a national antimicrobial stewardship surveillance system, with open access data sharing

BACKGROUND

Public Health England (PHE) developed an antimicrobial stewardship (AMS) surveillance system and conducted a national pilot to test the feasibility of centrally collecting data from AMS audits performed by NHS hospital trusts. The system was simplified, focusing on requirements of the NHS AMR CQUIN (Commissioning for Quality and Innovation; a financial incentive quality improvement scheme).

AIM

To present results and user feedback from the national pilot, and results from using the AMS surveillance system as part of the AMR CQUIN.

METHODS

An AMS surveillance system was developed and a national pilot conducted in which 33 NHS trusts submitted data and feedback on system utilization. The system was refined based on feedback and deployed nationally to collect AMS data for the 2016-17 AMR CQUIN.

FINDINGS

Most trusts participating in the pilot collected data on documentation of indication (90%). Fewer collected data on documenting review decisions at 48-72 h (36%). On average 83% of patients had an indication documented, whereas 71% had formal documentation of 48-72 h review. AMR CQUIN data were submitted by 88% of trusts for at least one quarter of 2016-17. Approximately 92% of prescriptions had an indication documented and 87.5% of prescriptions had evidence of review within 72 h; these increased by 7 and 10 percentage points respectively between the first and final quarters.

CONCLUSION

The AMS surveillance system allowed AMS audit data from NHS trusts in England to be collected centrally. PHE publishes these data openly online, on PHE Fingertips portal, a national public health data portal. The reported data highlight improvement in the percentage of antibiotic prescriptions with evidence of a documented review within 72 h.

Supply of care by dental therapists and emergency dental consultations in Alaska native communities in the Yukon-Kuskokwim delta: a mixed methods evaluation

OBJECTIVES

Examine the relationship between supply of care provided by dental therapists and emergency dental consultations in Alaska Native communities.

METHODS

Explanatory sequential mixed-methods study using Alaska Medicaid and electronic health record (EHR) data from the Yukon-Kuskokwim Health Corporation (YKHC), and interview data from six Alaska Native communities. From the Medicaid data, we estimated community-level dental therapy treatment days and from the EHR data we identified emergency dental consultations. We calculated Spearman partial correlation coefficients and ran confounder-adjusted models for children and adults. Interview data collected from YKHC providers (N=16) and community members (N=125) were content analysed. The quantitative and qualitative data were integrated through connecting. Results were visualized with a joint display.

RESULTS

There were significant negative correlations between dental therapy treatment days and emergency dental consultations for children (partial rank correlation = -0.48; p⟨0.001) and for adults (partial rank correlation = -0.18; p=0.03). Six pediatric themes emerged: child-focused health priorities; school-based dental programs; oral health education and preventive behaviors; dental care availability; healthier teeth; and satisfaction with care. There were four adult themes: satisfaction with care; adults as a lower priority; difficulties getting appointments; and limited scope of practice of dental therapy.

CONCLUSIONS

Alaska Native children, and to a lesser extent adults, in communities served more intensively by dental therapists have benefitted. There are high levels of unmet dental need as evidenced by high emergency dental consultation rates. Future research should identify ways to address unmet dental needs, especially for adults.

Enumeration of Total Aerobic Microorganisms in Foods by SimPlate® Total Plate Count–Color Indicator Methods and Conventional Culture Methods: Collaborative Study

The relative efficacy of the SimPlate® Total Plate Count–Color Indicator (TPC–CI) method (SimPlate 35°C) was compared with the AOAC Official Method 966.23 (AOAC 35°C) for enumeration of total aerobic microorganisms in foods. The SimPlate TPC–CI method, incubated at 30°C (SimPlate 30°C), was also compared with the International Organization for Standardization (ISO) 4833 method (ISO 30°C). Six food types were analyzed: ground black pepper, flour, nut meats, frozen hamburger patties, frozen fruits, and fresh vegetables. All foods tested were naturally contaminated. Nineteen laboratories throughout North America and Europe participated in the study. Three method comparisons were conducted. In general, there was &lt;0.3 mean log count difference in recovery among the SimPlate methods and their corresponding reference methods. Mean log counts between the 2 reference methods were also very similar. Repeatability (sr) and reproducibility (sR) standard deviations were similar among the 3 method comparisons. The SimPlate method (35°C) and the AOAC method were comparable for enumerating total aerobic microorganisms in foods. Similarly, the SimPlate method (30°C) was comparable to the ISO method when samples were prepared and incubated according to the ISO method.

Visual Immunoprecipitate Assay Eight Hour Method for Detection of Enterohemorrhagic Escherichia coli O157:H7 in Raw and Cooked Beef (Modification of AOAC Official Method 996.09): Collaborative Study

AOAC Official Method 996.09, Visual Immunoprecipitate Assay (VIP®) for Escherichia coli O157:H7, was modified to incorporate a new enrichment protocol using BioControl EHEC8™ medium for testing raw and cooked beef. Foods were tested by VIP assay and the U.S. Department of Agriculture/Food Safety and Inspection Service (USDA/FSIS) enrichment procedure and the FDA Bacteriological Analytical Manual (BAM) isolation and confirmation techniques. A total of 15 collaborators participated. Raw and cooked ground beef were inoculated with E. coli O157:H7 at 2 different levels: a high level, where predominantly positive results were expect d, and a low level where fractional recovery was anticipated. Collaborators tested 396 test portions and controls by both methods, for a total of 792 test portions. Of the 396 paired test portions, 75 were positive and 230 were negative by both the VIP and culture methods. Eleven test portions were presumptively positive by VIP and could not be confirmed culturally; 32 were negative by VIP, but confirmed positive by culture; and 65 were negative by the culture method, but confirmed positive by the VIP method. There was no statistical difference between results obtained with the VIP for EHEC 8 h method and the culture method except for cooked beef, where the VIP had significantly higher recovery for one inoculation level.

Assurance® Enzyme Immunoassay Eight Hour Method for Detection of Enterohemorrhagic Escherichia coli O157:H7 in Raw and Cooked Beef (Modification of AOAC Official Method 996.10): Collaborative Study

AOAC Official Method 996.10, Assurance® Enzyme Immunoassay (EIA) for Escherichia coli O157:H7 (EHEC), was modified to incorporate a new enrichment protocol using BioControl EHEC8™ medium for testing raw and cooked beef. Foods were tested by EIA and the U.S. Department of Agriculture/Food Safety and Inspection Service (USDA/FSIS) enrichment conditions and the FDA Bacteriological Analytical Manual (BAM) isolation and confirmation techniques. A total of 14 collaborators participated. Raw and cooked ground beef were inoculated with E. coli O157:H7 at 2 different levels: a high level where predominantly positive results were expected, and a low level where fractional recovery was anticipated. Collaborators tested 378 test portions and controls by both the 8 h EIA and the USDA/FSIS enrichment methods, for a total of 756 test portions. Of the 378 paired test portions, 75 were positive and 212 were negative by both methods. Thirteen test portions were presumptively positive by EIA and could not be confirmed culturally; 30 were negative by EIA, but confirmed positive by culture; and 65 were negative by the culture method, but confirmed positive by the EIA method. There was no statistical difference between results obtained with the Assurance EIA for EHEC 8 h method and the culture method for raw ground beef. The Assurance EIA had a significantly higher recovery for cooked beef.

How do surgeons feel about the 'Getting it Right First Time' national audit? Results from a qualitative assessment

The implementation of the national 'Getting It Right First Time' was assessed by interviewing six surgeons involved at various levels in surgical site infection (SSI) audit. The positive impacts were to create new professional collaboration, improve stakeholder engagement, and increase the profile of SSIs. One particular knowledge gap highlighted was that some participants had been unaware until that point of the criteria for diagnosing an SSI. The quality of data collected was felt to be poor due to methodological flaws. The audit was described as highly time-consuming and unsustainable if leaning on junior surgeons, without protected time and designated responsibility.

A national quality incentive scheme to reduce antibiotic overuse in hospitals: evaluation of perceptions and impact

Background

In 2016/2017, a financially linked antibiotic prescribing quality improvement initiative Commissioning for Quality and Innovation (AMR-CQUIN) was introduced across acute hospitals in England. This aimed for >1% reductions in DDDs/1000 admissions of total antibiotics, piperacillin/tazobactam and carbapenems compared with 2013/2014 and improved review of empirical antibiotic prescriptions.

Objectives

To assess perceptions of staff leading antimicrobial stewardship activity regarding the AMR-CQUIN, the investments made by hospitals to achieve it and how these related to achieving reductions in antibiotic use.

Methods

We invited antimicrobial stewardship leads at acute hospitals across England to complete a web-based survey. Antibiotic prescribing data were downloaded from the PHE Antimicrobial Resistance Local Indicators resource.

Results

Responses were received from 116/155 (75%) acute hospitals. Owing to yearly increases in antibiotic use, most trusts needed to make >5% reductions in antibiotic consumption to achieve the AMR-CQUIN goal of 1% reduction. Additional funding was made available at 23/113 (20%) trusts and, in 18 (78%), this was <10% of the AMR-CQUIN value. Nationally, the annual trend for increased antibiotic use reversed in 2016/2017. In 2014/2015, year-on-year changes were +3.7% (IQR -0.8%, +8.4%), +9.4% (+0.2%, +19.5%) and +5.8% (-6.2%, +18.2%) for total antibiotics, piperacillin/tazobactam and carbapenems, respectively, and +0.1% (-5.4%, +4.0%), -4.8% (-16.9%, +3.2%) and -8.0% (-20.2%, +4.0%) in 2016/2017. Hospitals where staff believed they could reduce antibiotic use were more likely to do so (P < 0.001).

Conclusions

Introducing the AMR-CQUIN was associated with a reduction in antibiotic use. For individual hospitals, achieving the AMR-CQUIN was associated with favourable perceptions of staff and not availability of funding.

Epidemiology and health-economic burden of urinary-catheter-associated infection in English NHS hospitals: a probabilistic modelling study

BACKGROUND

Catheter-associated urinary tract infection (CAUTI) and bloodstream infection (CABSI) are leading causes of healthcare-associated infection in England's National Health Service (NHS), but health-economic evidence to inform investment in prevention is lacking.

AIMS

To quantify the health-economic burden and value of prevention of urinary-catheter-associated infection among adult inpatients admitted to NHS trusts in 2016/17.

METHODS

A decision-analytic model was developed to estimate the annual prevalence of CAUTI and CABSI, and their associated excess health burdens [quality-adjusted life-years (QALYs)] and economic costs (£ 2017). Patient-level datasets and literature were synthesized to estimate population structure, model parameters and associated uncertainty. Health and economic benefits of catheter prevention were estimated. Scenario and probabilistic sensitivity analyses were conducted.

FINDINGS

The model estimated 52,085 [95% uncertainty interval (UI) 42,967-61,360] CAUTIs and 7529 (UI 6857-8622) CABSIs, of which 38,084 (UI 30,236-46,541) and 2524 (UI 2319-2956) were hospital-onset infections, respectively. Catheter-associated infections incurred 45,717 (UI 18,115-74,662) excess bed-days, 1467 (UI 1337-1707) deaths and 10,471 (UI 4783-13,499) lost QALYs. Total direct hospital costs were estimated at £54.4M (UI £37.3-77.8M), with an additional £209.4M (UI £95.7-270.0M) in economic value of QALYs lost assuming a willingness-to-pay threshold of £20,000/QALY. Respectively, CABSI accounted for 47% (UI 32-67%) and 97% (UI 93-98%) of direct costs and QALYs lost. Every catheter prevented could save £30 (UI £20-44) in direct hospital costs and £112 (UI £52-146) in QALY value.

CONCLUSIONS

Hospital catheter prevention is poised to reap substantial health-economic gains, but community-oriented interventions are needed to target the large burden imposed by community-onset infection.

An evaluation of the electronic reporting system for the enhanced surveillance of carbapenemase-producing Gram-negative bacteria in England

BACKGROUND

An electronic reporting system (ERS) for the enhanced surveillance of carbapenemase-producing Gram-negative bacteria (CPGNB) was launched by Public Health England in May 2015.

AIM

This evaluation aimed to assess uptake, timeliness and completeness of data provided and explore potential barriers and facilitators to adopting the system.

METHODS

The evaluation comprised a retrospective analysis of surveillance data and semi-structured interviews with ERS users.

FINDINGS

The proportion of organisms referred for investigation of carbapenem resistance via ERS increased over the first 12 months post-implementation from 35% to 73%; uptake varied widely across regions of England. Completeness of enhanced data fields was poor in 78% of submitted isolates. The median number of days to report confirmatory test results via ERS was 1 day for the regional service and nine days for the national reference laboratory, which additionally conducts phenotypic testing to confirm carbapenemase negativity. Hindrances to ERS utility included: a lack of designated, ongoing resource for system maintenance, technical support and development; uncertainty about how and when to use ERS and workload. Incomplete data prevented gaining a better understanding of important risk factors and transmission routes of CPGNB in England.

CONCLUSION

The ERS is the only surveillance system in England with the potential to gather intelligence on important risk factors for CPGNB to inform public health measures to control their spread. Although the ERS captures more information on CPGNB than other surveillance systems, timeliness and completeness of the enhanced data require substantial improvements in order to deliver the desired health benefits.

Discordance in latent tuberculosis (TB) test results in patients with end-stage renal disease

OBJECTIVES

This natural experiment was designed to assess the impact of exposure to an active case of tuberculosis (TB) on a group of immunosuppressed individuals, with end-stage renal disease over an extended follow-up.

STUDY DESIGN

Close contacts of people with sputum smear-positive Mycobacterium tuberculosis are at high risk of infection, particularly immunosuppressed individuals. An infectious TB healthcare worker worked in a renal dialysis unit for a month before diagnosis, with 104 renal dialysis patients, was exposed for ≥8 h.

METHODS

Patients were informed and invited for screening 8-10 weeks postexposure. They either underwent standard two-step assessment with tuberculin skin test (TST) and QuantiFERON^®-TB Gold (Cellestis GmbH; QFN) interferon-gamma release assay (IGRA) or after consent, enrolled in a study where these two tests were performed simultaneously with T-SPOT^®-TB (Oxford Immunotec Ltd; TSPOT). Patients within the study were followed up for 2 years from exposure, with QFN and TSPOT repeated at months 3 and 6 from the first testing.

RESULTS

Of 104 exposed individuals, 75 enrolled in the study. There was a high degree of discordance among QFN, TSPOT and TST. This was seen at both the first time point and also over time in subjects who were retested. No patients had active TB at the baseline testing. None received treatment for latent TB infection. Over the following 2 years, no one developed TB disease.

CONCLUSION

This study suggests that there is a low risk of progression to active TB in low-incidence countries even in high-risk groups. This plus the degree of the test result discordance emphasises the complexities of managing TB in such settings as it is unclear which of these tests, if any, provides the best diagnostic accuracy.

An evaluation of a toolkit for the early detection, management, and control of carbapenemase-producing Enterobacteriaceae: a survey of acute hospital trusts in England

BACKGROUND

Following hospital outbreaks of carbapenemase-producing Enterobacteriaceae (CPE), Public Health England published a toolkit in December 2013 to promote the early detection, management, and control of CPE colonization and infection in acute hospital settings.

AIM

To examine awareness, uptake, implementation and usefulness of the CPE toolkit and identify potential barriers and facilitators to its adoption in order to inform future guidance.

METHODS

A cross-sectional survey of National Health Service (NHS) acute trusts was conducted in May 2016. Descriptive analysis and multivariable regression models were conducted, and narrative responses were analysed thematically and informed using behaviour change theory.

FINDINGS

Most (92%) acute trusts had a written CPE plan. Fewer (75%) reported consistent compliance with screening and isolation of CPE risk patients. Lower prioritization and weaker senior management support for CPE prevention were associated with poorer compliance. Awareness of the CPE toolkit was high and all trusts with patients infected or colonized with CPE had used the toolkit either as provided (32%), or to inform (65%) their own local CPE plan. Despite this, many respondents (80%) did not believe that the CPE toolkit guidance offered an effective means to prevent CPE or was practical to follow.

CONCLUSION

CPE prevention and control requires robust IPC measures. Successful implementation can be hindered by a complex set of factors related to their practical execution, insufficient resources and a lack of confidence in the effectiveness of the guidance. Future CPE guidance would benefit from substantive user involvement, processes for ongoing feedback, and regular guidance updates.

Delays in the diagnosis and treatment of bone and joint tuberculosis in the United Kingdom

Aims

Tuberculosis (TB) infection of bones and joints accounts for 6.7% of TB cases in England, and is associated with significant morbidity and disability. Public Health England reports that patients with TB experience delays in diagnosis and treatment. Our aims were to determine the demographics, presentation and investigation of patients with a TB infection of bones and joints, to help doctors assessing potential cases and to identify avoidable delays.

Patients and Methods

This was a retrospective observational study of all adults with positive TB cultures on specimens taken at a tertiary orthopaedic centre between June 2012 and May 2014. A laboratory information system search identified the patients. The demographics, clinical presentation, radiology, histopathology and key clinical dates were obtained from medical records.

Results

A total of 31 adult patients were identified. Their median age was 37 years (interquartile range (IQR): 29 to 53); 21 (68%) were male; 89% were migrants. The main sites affected were joints (10, 32%), the spine (8, 26%) and long bones (6, 19%); 8 (26%) had multifocal disease. The most common presenting symptoms were pain (29/31, 94%) and swelling (26/28, 93%). ‘Typical’ symptoms of TB, such as fever, sweats and weight loss, were uncommon. Patients waited a median of seven months (IQR 3 to 13.5) between the onset of symptoms and referral to the tertiary centre and 2.3 months (IQR 1.6 to 3.4.)) between referral and starting treatment. Radiology suggested TB in 26 (84%), but in seven patients (23%) the initial biopsy specimens were not sent for mycobacterial culture, necessitating a second biopsy. Rapid Polymerase Chain Reaction-based testing for TB using Xpert MTB/RIF was performed in five patients; 4 (80%) tested positive for TB. These patients had a reduced time between the diagnostic biopsy and starting treatment than those whose samples were not tested (median eight days versus 36 days, p = 0.016).

Conclusion

Patients with bone and joint TB experience delays in diagnosis and treatment, some of which are avoidable. Maintaining a high index of clinical suspicion and sending specimens for mycobacterial culture are crucial to avoid missing cases. Rapid diagnostic tests reduce delays and should be performed on patients with radiological features of TB. Cite this article: Bone Joint J 2018;100-B:119–24.

A Review on Bone Mineral Density Loss in Total Knee Replacements Leading to Increased Fracture Risk

The link between low bone mineral density (BMD) scores leading to greater fracture risk is well established in the literature; what is not fully understood is the impact of total knee replacements/revisions or arthroplasties on BMD levels. This literature review attempts to answer this question. Several different databases using specific key terms were searched, with additional papers retrieved via bibliographic review. Based on the available evidence, total knee replacements/revisions and arthroplasties lower BMD and thus increase fracture risk. This review also addresses the possible implications of this research and possible options to reduce this risk.

Carriage of extended-spectrum beta-lactamase-producing Enterobacteriaceae in HIV-infected children in Zimbabwe

Background

Antimicrobial resistance is an emerging global health issue. Data on the epidemiology of multidrug-resistant organisms are scarce for Africa, especially in HIV-infected individuals who often have frequent contact with healthcare. We investigated the prevalence of extended-spectrum beta-lactamase-producing Enterobacteriaceae (ESBL-E) carriage in stool among HIV-infected children attending an HIV outpatient department in Harare, Zimbabwe.

Methods

We recruited children who were stable on antiretroviral therapy (ART) attending a HIV clinic from August 2014 to June 2015. Information was collected on antibiotic use and hospitalization. Stool was tested for ESBL-E through combination disc diffusion. API20E identification and antimicrobial susceptibility was performed on the positive samples followed by whole genome sequencing.

Results

Stool was collected from 175/202 (86.6 %) children. Median age was 11 [inter-quartile range (IQR) 9–12] years. Median time on ART was 4.6 years (IQR 2.4–6.4). ESBL-Es were found in 24/175 samples (13.7 %); 50 % of all ESBL-Es were resistant to amoxicillin-clavulanate, 100 % to co-trimoxazole, 45.8 % to chloramphenicol, 91.6 % to ceftriaxone, 20.8 % to gentamicin and 62.5 % to ciprofloxacin. ESBL-Es variously encoded CTX-M, OXA, TEM and SHV enzymes. The odds of ESBL-E carriage were 8.5 times (95 % CI 2.2–32.3) higher in those on ART for less than one year (versus longer) and 8.5 times (95 % CI 1.1–32.3) higher in those recently hospitalized for a chest infection.

Conclusion

We found a 13.7 % prevalence of ESBL-E carriage in a population where ESBL-E carriage has not been described previously. Antimicrobial resistance (AMR) in Africa merits further study, particularly given the high HIV prevalence and limited diagnostic and therapeutic options available.

Association of the missense variant p.Arg203Trp in PACS1 as a cause of intellectual disability and seizures

Graphical abstract key: ADHD, attention deficit hyperactivity disorder; ASD, atrial septal defect; DD, developmental delay; EEG, electroencephalogram; Ht, height; ID, intellectual disability; OCD, obsessive-compulsive disorder; OFC, open fontanelle; PDA, patent ductus arteriosis; PFO, patent foramen ovale; VSD, ventricular septal defect; Wt, weight.

Implementation of antimicrobial stewardship interventions recommended by national toolkits in primary and secondary healthcare sectors in England: TARGET and Start Smart Then Focus

OBJECTIVES

To assess and compare the implementation of antimicrobial stewardship (AMS) interventions recommended within the national AMS toolkits, TARGET and Start Smart Then Focus, in English primary and secondary healthcare settings in 2014, to determine the prevalence of cross-sector engagement to drive AMS interventions and to propose next steps to improve implementation of AMS.

METHODS

Electronic surveys were circulated to all 211 clinical commissioning groups (CCGs; primary sector) and to 146 (out of the 159) acute trusts (secondary sector) in England. Response rates were 39% and 63% for the primary and secondary sectors, respectively.

RESULTS

The majority of CCGs and acute trusts reported reviewing national AMS toolkits formally or informally (60% and 87%, respectively). However, only 13% of CCGs and 46% of acute trusts had developed an action plan for the implementation of these toolkits. Only 5% of CCGs had antimicrobial pharmacists in post; however, the role of specialist antimicrobial pharmacists continued to remain embedded within acute trusts, with 83% of responding trusts having an antimicrobial pharmacist at a senior grade.

CONCLUSIONS

The majority of healthcare organizations review national AMS toolkits; however, implementation of the toolkits, through the development of action plans to deliver AMS interventions, requires improvement. For the first time, we report the extent of cross-sector and multidisciplinary collaboration to deliver AMS interventions in both primary and secondary care sectors in England. Results highlight that further qualitative and quantitative work is required to explore mutual benefits and promote best practice. Antimicrobial pharmacists remain leaders for implementing AMS interventions across both primary and secondary healthcare sectors.

Characteristics associated with the consumption of malted drinks among Malaysian primary school children: findings from the MyBreakfast study

BACKGROUND

The consumption of beverages contributes to diet quality and overall nutrition. Studies on malted drinks, one of the widely consumed beverage choices among children in Asia, however, have received limited attention. This study aimed to examine the prevalence of malted drink consumption and explored associations of sociodemographic characteristics, nutrient intakes, weight status and physical activity levels with malted drink consumption among primary school children in Malaysia.

METHODS

Data for this analysis were from the MyBreakfast Study, a national cross-sectional study conducted from April to October 2013 throughout all regions in Malaysia. A total of 2065 primary school children aged 6 to 12 years were included in the present analysis. Data on two days 24-h dietary recall or record, anthropometry, physical activity and screen time were recorded. Associations between malted drink consumption and related factors were examined using binary logistic regression, adjusting for region, area, gender, ethnicity and household income.

RESULTS

Among children aged 6 to 12 years, 73.5% reported consuming malted drinks for at least once per week. Consumption of malted drinks was significantly associated with region (χ(2) = 45.64, p < 0.001), gender (χ(2) = 4.41, p = 0.036) and ethnicity (χ(2) = 13.74, p = 0.008). Malted drink consumers had similar total energy intake but higher micronutrient intakes compared to non-consumers. High physical activity level (OR = 1.77, 95% CI = 1.06, 2.99) and lower screen time during weekends (OR = 0.93, 95% CI = 0.86, 0.99) were independently associated with malted drink consumption among 6 to 9 year-old children, but not among 10 to 12 year-old children. No association was observed between malted drink consumption and weight status.

CONCLUSIONS

Malted drink consumption is prevalent among Malaysian primary school children, particularly higher among boys, indigenous children and those who lived in the East Coast region of Malaysia. Consuming malted drinks is associated with higher micronutrient intakes and higher levels of physical activity, but not with body weight status.

Associations between diet and cardiometabolic risk among Yup'ik Alaska Native people using food frequency questionnaire dietary patterns

BACKGROUND AND AIMS

In previous analyses, we identified three dietary patterns from food frequency questionnaire data among a sample of Yup'ik Alaska Native people living in Southwest Alaska: a "subsistence foods" dietary pattern and two market-based dietary patterns "processed foods" and "fruits and vegetables". In this analysis, we aimed to characterize the association between the dietary patterns and cardiometabolic (CM) risk factors (lipids, blood pressure, glucose, adiposity).

METHODS AND RESULTS

We used multilevel linear regression to estimate the mean of each CM risk factor, comparing participants in the 4th to the 1st quartile of each dietary pattern (n = 637). Models were adjusted for age, sex, past smoking, current smoking, and physical activity. Mean log triglyceride levels were significantly higher among participants in the 4th compared to the 1st quartile of the processed foods dietary pattern (β = 0.11). Mean HbA1c percent was significantly lower (β = -0.08) and mean diastolic blood pressure (DBP) mm Hg was significantly higher (β = 2.87) among participants in the 4th compared to the 1st quartile of the fruits and vegetables dietary pattern. Finally, mean log triglyceride levels and mean DBP mm Hg were significantly lower among participants in the 4th compared to the 1st quartile of the subsistence foods dietary pattern (β = -0.10 and β = -3.99 respectively).

CONCLUSIONS

We found increased CM risk, as reflected by increased triglycerides, associated with eating a greater frequency of processed foods, and reduced CM risk, as reflected by lower triglycerides and DBP, associated with eating a greater frequency of subsistence foods.

The reliability of the McCabe score as a marker of co-morbidity in healthcare-associated infection point prevalence studies

This study aimed to ascertain the reliability of the McCabe score in a healthcare-associated infection point prevalence survey.   A 10 European Union Member States survey in 20 hospitals (n = 1912) indicated that there was a moderate level of agreement (κ = 0.57) with the score. The reliability of the application of the score could be increased by training data collectors, particularly with reference to the ultimately fatal criteria. This is important if the score is to be used to risk adjust data to drive infection prevention and control interventions.

The role of immunophilins in viral infection

BACKGROUND

Tremendous progress has been made in the past 20 years in understanding the roles played by immunophilins, and in particular the cyclophilins, in supporting the replication cycles of human viruses. A growing body of genetic and biochemical evidence and data from clinical trials confirm that cyclophilins are essential cofactors that contribute to establishing a permissive environment within the host cell that supports the replication of HIV-1 and HCV. Cyclophilin A regulates HIV-1 replication kinetics and infectivity, modulates sensitivity to host restriction factors, and cooperates in the transit of the pre-integration complex into the nucleus of infected cells. Cyclophilin A is an essential cofactor whose expression supports HCV-specific RNA replication in human hepatocytes.

GENERAL SIGNIFICANCE

Peptidyl-prolyl isomerase inhibitors have been used in clinical trials to validate cyclophilins as antiviral targets for the treatment of HIV-1 and Chronic Hepatitis C virus infection and as molecular probes to identify the roles played by immunophilins in supporting the replication cycles of human viruses.

SCOPE OF REVIEW

This review summarizes emerging research that defines the functions of immunophilins in supporting the replication cycles of HIV-1, HCV, HBV, coronaviruses, and other viral pathogens and describes new information that suggests a role for immunophilins in regulating innate immune responses against chronic viral infection.

MAJOR CONCLUSIONS

The dependence on cyclophilins by evolutionarily distinct viruses for accomplishing various steps in replication such as viral entry, initiation of genomic nucleic acid replication, viral genome uncoating, nuclear import and nuclear entry, emphasizes the potential of cyclophilin inhibitors as therapeutic agents. This article is part of a Special Issue entitled Proline-directed Foldases: Cell Signaling Catalysts and Drug Targets.

A pilot validation in 10 European Union Member States of a point prevalence survey of healthcare-associated infections and antimicrobial use in acute hospitals in Europe, 2011

Binary file ES_Abstracts_Final_ECDC.txt matches

Novel agents and associated toxicities of inhibitors of the pi3k/Akt/mtor pathway for the treatment of breast cancer

The pi3k/Akt/mtor (phosphatidylinositol 3 kinase/ Akt/mammalian target of rapamycin) signalling pathway is an established driver of oncogenic activity in human malignancies. Therapeutic targeting of this pathway holds significant promise as a treatment strategy. Everolimus, an mtor inhibitor, is the first of this class of agents approved for the treatment of hormone receptor-positive, human epidermal growth factor receptor 2-negative advanced breast cancer. Everolimus has been associated with significant improvements in progression-free survival; however, it is also associated with increased toxicity related to its specific mechanism of action.

METHODS

A comprehensive review of the literature conducted using a focused medline search was combined with a search of current trials at http://ClinicalTrials.gov/. Summary tables of the toxicities of the various classes of pi3k/Akt/mtor inhibitors were created. A broad group of Canadian health care professionals was assembled to review the data and to produce expert opinion and summary recommendations for possible best practices in managing the adverse events associated with these pathway inhibitors.

RESULTS

Differing toxicities are associated with the various classes of pi3k/Akt/mtor pathway inhibitors. The most common unique adverse events observed in everolimus clinical trials in breast cancer include stomatitis (all grades: approximately 60%), noninfectious pneumonitis (15%), rash (40%), hyperglycemia (15%), and immunosuppression (40%). To minimize grades 3 and 4 toxicities and to attempt to attain optimal outcomes, effective management of those adverse events is critical. Management should be interdisciplinary and should use approaches that include education, early recognition, active intervention, and potentially prophylactic strategies.

DISCUSSION

Everolimus likely represents the first of many complex oral targeted therapies for the treatment of breast cancer. Using this agent as a template, it is essential to establish best practices involving and integrating multiple disciplines for the management of future pi3k/Akt/mtor signalling pathway inhibitors.

Expanded blood borne virus testing in a tuberculosis clinic. A cost and yield analysis

OBJECTIVES

Testing for HIV is a standard of care for people with active tuberculosis (TB). People investigated for TB in the UK often originate from areas with a high prevalence of HIV and other blood borne viruses (BBV). However, assessment for these infections is patchy. We determined the yield and costs of different testing strategies for BBV in a UK TB clinic.

METHODS

Since 2009, it has been routine to test all TB clinic attendees. Demographic, clinical and virological data were retrospectively extracted from patient notes and hospital databases.

RESULTS

Over 3 years, 1036 people were assessed in the TB service. 410 had a final diagnosis of active TB. HIV testing of the latter population diagnosed 27 new HIV cases at a cost of £3017. When BBV testing was offered to all clinic attendees, a further 6 (total 33) new HIV, 5 Hepatitis B (HBV) and 2 Hepatitis C (HCV) diagnoses were made at a total cost of £22,170.

CONCLUSIONS

We have identified previously undiagnosed HIV, HBV and HCV in a TB clinic population. Our data suggest that despite increasing upfront expense, the associated yield argues strongly for BBV testing to be offered to all patients being investigated for possible TB, irrespective of their final diagnosis.

Survey of neonatal unit outbreaks in North London: identifying causes and risk factors

BACKGROUND

This survey was undertaken after a number of neonatal unit (NNU) outbreaks were reported to the North London health protection teams (HPTs).

AIM

To determine the diversity of the outbreaks, ascertain potential sources and contributing factors, and identify the investigative procedures followed and control measures implemented.

METHODS

Using a structured questionnaire, information from the HPT database was collected for all NNU outbreaks reported between January 2010 and February 2011.

FINDINGS

Ten outbreaks were identified from seven hospitals in 14 months. There was one para-influenza outbreak, seven Staphylococcus aureus [including six meticillin-resistant S. aureus (MRSA)] outbreaks, and two Gram-negative outbreaks. Potential sources of transmission identified for the MRSA outbreaks were healthcare worker (HCW)-assisted transmission (N = 2) and mother-to-baby transmission with onward HCW-assisted transmission (N = 3). An environmental source with onward HCW-assisted transmission was documented for one of the Gram-negative outbreaks. Interventions included patient screening and enhanced cleaning (N = 10), isolating/cohorting affected neonates (N = 9), barrier nursing (N = 6), staff movement restrictions (N = 5), hand hygiene audits (N = 4), staff screening (N = 4), household contact screening (N = 3) and environmental sampling (N = 3). Potential contributing factors included inadequate staffing levels, cluttered unit, inadequate sterilization of communal milk-expressing equipment and inappropriate follow-up of MRSA results.

CONCLUSION

This survey determined the diversity of NNU outbreaks in North London, and highlighted the importance of a multi-faceted approach to outbreak control. These data will assist in the development of clinical standards for the prevention, control and reporting of NNU outbreaks, and guidance for best practice in NNUs.